A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener
What information is most closely correlated with these orders?
a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anesthesia.
d. The woman has an episiotomy.
ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.
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Why is the information obtained from a swab culture of a wound limited?
a. A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria. b. A negative culture may not indicate infection because chronic wounds are often colonized with bacteria. c. Most wound infections are viral, so the swab culture would not be indicative of a wound infection. d. A swab culture result does not include bacterial sensitivity information necessary to provide treatment.
The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding?
a. Dilation of the pupils b. Consensual light reflex c. Conjugate movement of the eyes d. Convergence of the axes of the eyes
Which can the nurse safely delegate to the unlicensed assistive personnel (UAP)?
1. Initial assessment of pain 2. Regular reassessment of pain 3. Providing a massage and repositioning the client in pain 4. Administration of an oral analgesic
The nurse clarifies that anxiety disorders differ from normal anxiety in that anxiety disorders:
a. develop into suicidal tendencies. b. are seldom controlled. c. interfere with effective functioning. d. make maintenance of relationships im-possible.